Archive for September, 2010

Child care at the workplace was a brand new phenomenon in World War II. The government-subsidized Kaiser West Coast Shipyards nursery schools, which enrolled more than 7,000 offspring of women war workers, offered the perfect opportunity to test theories of the then-fledgling field of child development.

In 1943, Henry J. Kaiser invited key figures in child development studies to his shipyards to set up ideal facilities and programs so workers could build ships without worrying about the safety and health of their children. These model child care centers at the Kaiser shipyards in Richmond, California, and Portland, Oregon, yielded valuable research results that helped fuel the study of early childhood education for decades after the war.

Catherine Landreth, PhD, of the University of California, Berkeley, set up the Richmond schools program. Lois Meek Stolz, PhD, a child development researcher and author from Columbia University and UC Berkeley, set up the Portland centers. James L. Hymes, Jr., a student of Stolz at Columbia, served as manager of the Portland centers.

Stolz and Landreth continued to exert influence on the child development world until the end of their lives. But it was Hymes, just 30 at war’s end, who would become a prodigious contributor to the child development literature for the next five decades. His work is often quoted today. One such quote reflects lessons from the home front: “Every day-care center, whether it knows it or not, is a school. The choice is never between custodial care and education. The choice is between unplanned and planned education, between conscious and unconscious education, between bad education and good education.”

Early Hymes work discovered this summer

Recently, my colleagues and I unearthed the final report of the two Portland Kaiser wartime child development centers, along with a series of seven pamphlets written for postwar child care providers. We found these documents, mainly written by Hymes, in the Institute of Governmental Studies Library in the basement of UCB’s Moses Hall. They were originally filed in 1946 in the Library for Economic Research at Berkeley.

The series of pamphlets includes: 1) A Social Philosophy from Nursery School Teaching; 2) Must Nursery Teachers Plan? 3) Who Will Need a Post-War Nursery School? 4) Meeting Needs: The War Nursery Approach; 5) The Role of the Nutritionist; 6) Large Groups in Nursery School; 7) Should Children Under Two Be in the Nursery School? Two unnumbered pamphlets titled “Toys to Make” and “Recipes for Foods for Children” were also mentioned in the report but copies are not available in the library. Teachers bought a total of 2,582 pamphlets at 15 cents each, according to the report dated December 1945.

Pamphlets offer nuggets

The pamphlet titled “Should Children Under Two Be in Nursery School?” addressed an issue the child care centers were forced to face head-on during the war. Generally, nursery schools did not take children under 2 because experiments had shown the younger children did not thrive in group settings. But the demand for care for infants was too high in the shipyards to ignore. They agreed to accept children as young as 18 months, and in Oregon alone the centers enrolled 904 children 18 to 24 months of age.

“We therefore set out to plan a program which would include among other things: Provision for close and continuous relation of each child with one adult who would be responsible for him especially during eating, toileting and sleeping and during any time of emotional stress when he needed ‘mothering,’ ” wrote Stolz and Hymes.

Good food for good health

Another key wartime lesson: “Food influences behavior. Small children…have pounded into us in unforgettable ways that hungry people are irritable; that they fight more; that they cry easily; that they become destructive…Some children we have seen, hungrier still, have told us that hunger can make people placid, inactive, lethargic,” Hymes wrote. In pamphlet 5, Miriam Lowenberg, chief nutritionist, discussed the crucial link between food and good health: “The (nursery school) nutritionist (helps) teachers … bring the child who needs medical care to the attention of a visiting nurse or doctor.”

The final report discussed other crucial issues such as: the need for child care services after the war for low-income women, costs of the child care operation including nourishing meals, methods of recruiting and retaining qualified teachers, nurses and counselors, providing weekly onsite professional development, and offering opportunities for staff to participate in policy decisions. Attempts to maintain a 10:1 child-to-teacher ratio for the children over 2 and a 5:1 ratio for the infants 18 to 24 months were mostly successful, the authors reported.

Kaiser experts shine on after war

After the war ended, Hymes gained national recognition as an author. Among his earliest best-selling booklets was “A Pound of Prevention” in 1947, which advised first-grade teachers on how to handle difficult “war babies.” He wrote that the “crybabies, whiners and bullies” were still suffering from the disruption of war. Hymes also wrote “How to Tell Your Child About Sex” (1949), “Behavior and Misbehavior: A Teacher’s Guide to Discipline” (1957), “Teaching the Child Under Six” (1968), and “Twenty Years in Review: A Look at Early Childhood Education 1971-1990.”

Hymes served in the Lyndon Johnson administration on the National Planning Committee for Head Start. He and Catherine Landreth both were instrumental in the development of the educational program for low-income children. Landreth was also known for her groundbreaking research in social perception. One of her studies found that children learn racial prejudice from their parents as early as three years old. She wrote three books that were influential in shaping early childhood education: “Education of the Young Child” (with Katherine H. Read), 1942; “The Psychology of Early Childhood,” 1958; and “Preschool Learning and Teaching,” 1972.

After the war, Stolz published “Father Relations of War-Born Children,” a study of how father-child relationships were affected by a father’s absence for war duty (1954); “Our changing understanding of young children’s fears, 1920-1960” (1964), among other related works.

By Ginny McPartland
When we talk about quality of care today, the name “Jim Vohs” inevitably comes up. That’s because many Kaiser Permanente (KP) people have heard of the annual James A.Vohs Award for Quality. It’s a great honor to receive the Vohs award, and every year since 1997 people across the program have pulled out all stops to garner the coveted distinction for quality improvement projects. But fewer people know the story of James A. Vohs, the man behind the name, and why he is associated with quality assurance.

Jim Vohs was an early health plan leader, a champion of prepaid, group medical practice, a believer in strong partnerships between health plans and the medical groups, and an adamant advocate for Kaiser Foundation Health Plan and Hospitals as nonprofit institutions that provide quality, affordable health care.

Right out of Berkeley High School in 1946, Vohs first worked as a “mail boy” for a Kaiser Industries unit called Kaiser Services, where his mother worked as a bookkeeper. After his graduation from UC Berkeley in 1952, he rejoined Kaiser Services, which provided administrative support for the various Kaiser industrial companies, like Kaiser Steel, Kaiser Aluminum and Kaiser Engineers.

With his career blossoming, he shocked his Kaiser Services colleagues by choosing to switch to the nonprofit Kaiser Foundation Health Plan and Hospitals in 1957 because he believed in its principles. It was a good choice. During a 50-plus year career, he rose to become President and CEO as well as the first chairman of Foundation Health Plans and Hospitals boards of directors who was not a Kaiser family member, succeeding Edgar F. Kaiser, Henry J. Kaiser’s son.

Quality a big priority

Quality of care was an issue early on in the life of the Kaiser Permanente Medical Care Program. Detractors of prepaid, group practice were quite happy to spread rumors about how Kaiser Permanente doctors were not qualified or competent and that their patients were “captives” of no choice.

Vohs was very much aware that these attacks contributed to a “poor reputation,” however wrong, in KP’s early days. Even the prevailing attitude at Kaiser Services was that the medical care program was an “embarrassment.”

Meanwhile, Kaiser Permanente was early and quick in its efforts to show the skeptical world evidence of its excellent care. Early physicians published research that showcased their innovative treatment, sponsored medical symposiums, aligned themselves with academic medicine, and kept their heads down when the insults were hurled.

Reputation aside, Jim Vohs had faith in the high caliber of Permanente physicians, and he bravely faced critics who implied Permanente cut corners in medical treatment. “It is quite clear to me that the economic incentive . . . for the program and the participating physicians —who by and large spend their careers (with Permanente) — is to resolve medical problems as promptly and completely as possible,” Vohs told an interviewer in 1983.

Documenting quality of care

Today’s medical quality movement got its start with the creation of the Joint Commission on the Accreditation of Hospitals in 1952. The federal government started requiring quality data following the adoption of Medicare for the retired and Medicaid for the poor in 1965. The American Hospital Association published its Quality Assurance for Medical Care in the Hospital in 1972. The HMO (Health Maintenance Organization) act of 1973 required each federally qualified HMO to have an internal quality assurance program.

In 1974, Kaiser Permanente physicians from all regions started meeting regularly to discuss quality related issues, and Vohs established a department of quality and a board of directors committee on quality assurance. The committee, including Vohs, made site visits to each of the regions several times a year.

In 1979, Drs. Leonard Rubin and Sam Sapin served on an advisory committee that set up the National Committee for Quality Assurance (NCQA), which sets standards for HMOs. The Permanente physicians were successful in getting the committee to adopt a problem-focused approach to quality assessment, which Rubin had developed and tested starting in 1967.

By 1983, Kaiser Permanente was getting good reviews. Dr. Sapin reports: “Almost without exception, published reports comparing health care delivery by Kaiser Permanente physicians to others have shown us to be better than or at least equal to others.”

Vohs award perpetual trophy. Symbol of unity.

Vohs is proud of having the quality award as part of his legacy: “It’s so important for Kaiser Permanente. The regions are competing for the award; they are supporting programs in quality because they want to win that award.”

Vohs a key player in KP milestones

Throughout the years, Vohs played a key role in many of the milestones of Kaiser Permanente’s history. Each chapter helped to make Kaiser Permanente stronger and more capable of providing high quality care.

• Passing of the Federal Employees Benefits Act in 1959. This legislation was heavily influenced by Kaiser Permanente leaders who urged Congress to include a choice of fee-for-service and prepaid medical plans. Kaiser Permanente gained many members as a result.

• Passing of the HMO Act of 1973. Kaiser Permanente leaders also heavily influenced this legislation. They worked with Health, Education and Welfare Agency officials to develop a proposal for a per-person or capitation method of Medicare reimbursement for health maintenance organizations (HMOs), which became part of the act.

• Formalizing Equal Employment Opportunities (EEO) and Affirmative Action practices in the 1960s and 1970s. Opening a Kaiser Permanente EEO conference in 1976, Vohs reaffirmed Kaiser Permanente’s commitment to the employment of minorities and women. He reported an increase of minority and women employees from 4,600 in March 1974 to 5,084 a year later, almost one third of the total work force at the time. Women held 56 percent of the management or supervisory positions in 1975, up 2 percent from 1975; minorities held 14 percent of the top jobs in 1975, compared to 13 percent a year earlier.

Vohs affirmed KP’s historical “one-door, one-class” system of health care dating back to 1945. “Each member is entitled to necessary medical care of the same quality, in the same place, irrespective of income, race, religion or age. Given this policy, it would make little sense if we were to discriminate in our employment practices.”

• Partnership and eventual takeover of the Georgetown Health Plan strategically located in Washington, D.C. This medical care program provided the springboard for the creation of our Mid-Atlantic States region.

• Convening a meeting among health plan and medical group leaders in 1996 to re-confirm the principles of the historic 1955 Tahoe Agreement. The earlier agreement set up the business relationship and clear authorities for the Kaiser Permanente Health Plan and Hospitals leadership and the Southern and Northern California medical groups. Forty years later, the outcomes of “Tahoe II” were the National Partnership Agreement and the creation of the physicians’ Permanente Federation, which represents all regional medical groups in dealings with the health plan leadership.

Kaiser Permanente on a mission

An able administrator, Vohs believed in the health plan: “There was a sense of commitment to a program that was performing social good and demonstrating a way of providing care and financing that was important to the country.”

Vohs firmly dispatched any insinuation that Kaiser Permanente was like for-profit health plans: “Over the years, Kaiser Permanente has been driven by particular values that essentially relate to providing quality medical care to enrolled members for a fixed monthly premium. We don’t conceive of ourselves as a commercial enterprise,” Vohs told John K. Iglehart of Health Affairs in 1983. Quoted in a New York Times article “King of the HMO Mountain” the same year, Vohs added: “There’s a certain missionary zeal in what we’re doing. We think this is a good model for the way in which medical care ought to be organized – so we want to see it spread.”

The Southern California Region’s Proactive Office Encounter (POE), which promotes preventive care, and the California regions’ programs to prevent heart attacks and strokes, were awarded the 2009 Vohs Awards earlier this year. The Fall 2010 issue of the Permanente Journal carries an article about the POE.

Few care givers are more deserving of mention this week than the acute care nurse.

As anyone who has spent time in a modern hospital can tell you, the nurse is the linchpin of care delivery in a complex, sometimes frenzied and chaotic environment. Ask any hospital nurse what he needs in a typical shift and he likely will ask for more time bedside with patients. Nursing is a caring profession in desperate need of time for one-to-one communication between the nurse and the patient.

At Kaiser Permanente’s Sidney R. Garfield Health Care Innovation Center, a design lab that models and tests care delivery innovations, I recently learned of a study underway to increase the time that the care nurse has with the patient. I’ll say more about “Destination Bedside” in a moment.

To free the nurse for time with the patient is not a new problem in care delivery. Over fifty years ago San Francisco architect Clarence Mayhew and Kaiser Permanente’s founding physician, Sidney R. Garfield, earned industry accolades for a hospital design that took-on this problem. “Efficiency Centers on the Corridor” published in The Modern Hospital, March 1954, covered the layout and design of the new Kaiser Foundation Hospital in Walnut Creek, California. What was the problem asked the writer in The Modern Hospital with the conventional designs of the era? “Simply stated . . . the patient’s charts, medicines . . . equipment and utilities which the nurse uses in her work are too far removed from the patient.”

The dedicated central work corridor at the Walnut Creek hospital, 1954.

The design solution was a new work corridor for the exclusive use of the care providers in the Walnut Creek hospital. “The [dedicated] central corridor becomes work space, and the nurses’ station, utility equipment, drugs, x-rays . . . linens, charts and so on for each patient can be kept in this work space just behind the patient’s room.” It was estimated the dedicated corridor would save six out of every seven steps a nurse takes in a conventional design and would offer immediate proximities to the patient. Nurses themselves have validated the design saying that the corridor enhanced patient privacy and one-to-one communication between nurse and patient.

Time marches on. The advance of medical knowledge, patient information systems, and biomedical and robotic devices have added layers of complexity to an already complex environment.

A few years ago a 36-hospital, nation-wide, time and motion study of nurse activities in acute care hospital settings was funded by the Robert Wood Johnson Foundation and the Gordon & Betty Moore Foundation. Ascension Health of St. Louis, Missouri, Kaiser Foundation Hospitals, Duke University Health System, New York-Presbyterian (the University Hospital of Columbia and Cornell universities), Vanderbilt University, Inova Health System, Carolinas Health System, and Intermountain Health, participated in the study. Findings were reported in The Permanente Journal.

What emerged from the time and motion study was a picture of the hospital nurse “who is constantly moving from patient room to room, nurse station to supply closet and back to room, spending a minority of time on [direct] patient care . . . and a greater amount of time on documentation, the coordination of care [services], medication administration, and movement around the unit.”

In a typical 10-hour shift, the authors found that less than one fifth of nurse time was given to direct patient care. Thirty-five percent of nurse time was given to care documentation, 21 percent of time to care coordination, 17 percent of time in medication administration, and 7 percent of time was given to patient assessment and vital signs. Only 19 percent of the time in a 10-hour shift was devoted to patient bedside activities.

Which brings me back around to the study I heard about at the Garfield Center. “Destination Bedside” design engineers are seeking solutions that minimize chaotic disruptions to nurse care and others that enable the nurse to spend less time charting, arranging for care services, or hunting for equipment, and more time in direct patient care activities. The integrated suite of process changes, some hi tech and some not, include among other things, an efficient transfer of patient information at bedside during nurse shift changes. They include a medication administration program that reduces interruptions to improve patient safety. They employ wireless hand held devices that free the nurse from the nurse station to move bedside with care documentation. They also improve upon the deployment of equipment and supplies.

Pilot implementations are in progress at Kaiser Foundation hospitals with nurse time in patient rooms up 19.6 percent at two pilot locations.

This week we acknowledge the complexity that confronts the hospital care nurse and commend Kaiser Permanente for it’s commitment to free-up time for the nurse to do what nurses feel called to do: care for their patients.